The UK needs more generalists, but where will they come from?

Authors: Abi Rimmer

Publication date:
08 Mar 2017

Abi Rimmer explores what progress has been made in boosting the generalist workforce

Rising multimorbidity, an ageing population, and the increasing specialisation of medical treatment are all driving a need to increase the number of doctors with generalist skills. And this need has been repeatedly emphasised in reviews of the future of the medical workforce.

In 2013 the Shape of Training review argued that postgraduate training needed to adapt to prepare graduates to deliver safe and effective general care and that general care should continue to be given within specialty areas.[1] The report also recommended that all doctors should be able to manage acutely ill patients with multiple comorbidities within their broad specialty areas.

In 2014, Labour’s then shadow health secretary, Andy Burnham, said that the NHS needed a new generation of generalists working in single clinical teams that were based on the patient’s needs and that were not attached to a particular institution. “I think it does mean breaking down the silos, breaking down the hierarchy,” he said.[2]

More recently, the House of Lords NHS sustainability committee heard from several experts that doctors’ training needed to be geared towards producing generalists instead of specialists, and broader ranging so that they are better prepared to deal with multimorbidity.[3]

Already working as generalists

Andrew Goddard, registrar at the Royal College of Physicians (RCP), says that, while hospital doctors may have focused too greatly on specialisation in the past, it would be a mistake to assume that they weren’t already working as generalists. “There is no doubt that we have swung too far towards just doing specialist and sub-specialist work and we need to swing back to generalism,” he says. “But the answer isn’t to suddenly go back to everybody just being a generalist and nobody doing a specialty.”

One of the problems that the NHS has, Goddard says, is not just a lack of generalists but a lack of doctors. “There are some consultants, a very small number, who just practise in their specialty and don’t do any general medicine,” Goddard says. “But half of my patients come in with a general medical problem, and virtually all of them have comorbidities, so I have to work as a generalist. That’s why we train people in both their specialty and in internal medicine.”

He added, “The big problem is trying to decide what model we are going to train for. The right thing to do is to continue to train specialists, but we need to make sure that we train them with generalist skills as well, so they can support generalists.”

Goddard said that the RCP would shortly be publishing a report that would look at the issue of training hospital doctors with generalist skills. The report “talks about the conditions that people might have on a ward that could be defined as specialist but actually all physicians need to be able to look after,” he says.

The report will look at the need to ensure that doctors have both the generalist skills to treat patients when they need to, but also the ability to know when a patient needs to be referred to a specialist, Goddard says. “Just because you are one person doesn’t mean you can’t have two sets of skills. Most of the general medicine that is currently delivered is delivered by specialists, and we have a model that works so we have to be careful about how we reinvent it.”

There is also an issue, Goddard says, around raising the profile of [what?]. “We need internal medicine to be something that people really aspire to,” he says. “It used to be that the professor of medicine was the top job in the hospital but now doing internal medicine is seen as something that distracts from specialties.”

Thinking holistically

Kamila Hawthorne, vice chair of the Royal College of GPs, also thinks that the profile of generalism needs to be improved. She says this could be done by teaching doctors to be generalists in medical school. “I think it needs to start right from undergraduate training. We need to produce doctors who are first and foremost generalists,” she says.

“That would mean a real change in the way we organise training. Right from the start, students should be taught to put patients at the centre of their learning, and to think holistically about people.”

Hawthorne says that this kind of teaching would encourage more students to become GPs, “because they would have been exposed to role models and a generalist approach to medical care, and it will no longer be seen as second best.”

Krishna Kasaraneni, the BMA’s lead on GP education, training, and workforce, argues that the best form of generalism currently is general practice. He adds, “Do I pander to the rhetoric of ‘everybody gets less general training now and therefore needs more general training’? No, that’s nonsense. Everybody gets training, training is being pushed because of funding cuts and lack of capacity.”

Kasaraneni adds, “Every now and then trainees are told, ‘We need to look at your training because we’re not delivering the service that’s required for the population.’ That’s not because of the training—it’s because bureaucracy has made it difficult to deliver care to patients.”